natashalage
Expert
Hello OBGYN coders, professionals.
I am new to this specialty and there is So Much to learn. I will greatly appreciate your answer to my question. Thank you!
The question is do we code Sentinel lymph node (SNL) resection separately from Vulvectomy Or you use a combined code 56631? I will give you more details. Let's say MD is performing Radical Partial Vulvectomy- 56630. MD also did mapping 38900 and resected SNL in inguinofemoral area. Pt has no tumor per Op note and pathology. Per Path- only one SNL was submitted.
To me: we use 56631 when Deep lymph nodes are removed or MD specifically says' lymphadenectomy is performed." I would code SNL separately as 38531 along with vulvectomy 56630 and mapping 38900.
56631- Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy
38531-Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
38900-ntraoperative identification (eg, mapping) of sentinel lymph node(s)....
Here is Op note for more details:
Procedure:
1. Left inguinofemoral sentinel lymph node mapping with indocyanine green
2. Excision of left sentinel lymph node ("hot", not green)
3. Left vulvar excision to fascia
Findings:
1. Examination under anesthesia was notable for no clinically palpable nodes.
2. There was evidence of a prior scar along the left labia with millimeter amount of residual ulceration visible.
3. Lymphoscintigraphy identified a left sentinel lymph node lying medial to the femoral artery. ICG mapping failed
“….
The femoral artery was identified and a hot node was then identified at the proximal medial side of this vessel. The lymph node was tested with the lymphoscintigraphy gamma probe and was noted to have activity in the 6,000s. This lymph node was elevated with Singley forceps and dissected away from the artery and lymphatic tissue. The inferior margin of the specimen was ligated, divided, and removed. The gamma probe confirmed this to be the sentinel lymph node with detection numbers in the 6,000s. The inguinal node site was irrigated and excellent hemostasis was noted. Camper's fascia was approximated with 2-0 vicryl. The sub-dermis was re-approximated with 3-0 Vicryl. The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.
We then turned our attention to the vulvar excision.
The vulva was marked with a fusiform shape with care to obtain a 1-2cm margin around the visible scar. There was no gross residual visible disease. The medial margin was modest in order to preserve the patient's clitoris. A scalpel was used to incise the dermis and epidermis and the subcutaneous fat was then dissected away from the fascia. The fusiform shaped specimen was marked and then sent to pathology for review.
Specimen(s) Received
A:Left inguinal sentinel lymph node
B:Left partial radical vulvectomy
C:Left partial radical vulvectomy, medial margin
FINAL PATHOLOGIC DIAGNOSIS
A. Left inguinal sentinel lymph node, biopsy: No tumor in one lymph node (0/1).
B. left vulva: No residual invasive squamous cell carcinoma
I am new to this specialty and there is So Much to learn. I will greatly appreciate your answer to my question. Thank you!
The question is do we code Sentinel lymph node (SNL) resection separately from Vulvectomy Or you use a combined code 56631? I will give you more details. Let's say MD is performing Radical Partial Vulvectomy- 56630. MD also did mapping 38900 and resected SNL in inguinofemoral area. Pt has no tumor per Op note and pathology. Per Path- only one SNL was submitted.
To me: we use 56631 when Deep lymph nodes are removed or MD specifically says' lymphadenectomy is performed." I would code SNL separately as 38531 along with vulvectomy 56630 and mapping 38900.
56631- Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy
38531-Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
38900-ntraoperative identification (eg, mapping) of sentinel lymph node(s)....
Here is Op note for more details:
Procedure:
1. Left inguinofemoral sentinel lymph node mapping with indocyanine green
2. Excision of left sentinel lymph node ("hot", not green)
3. Left vulvar excision to fascia
Findings:
1. Examination under anesthesia was notable for no clinically palpable nodes.
2. There was evidence of a prior scar along the left labia with millimeter amount of residual ulceration visible.
3. Lymphoscintigraphy identified a left sentinel lymph node lying medial to the femoral artery. ICG mapping failed
“….
The femoral artery was identified and a hot node was then identified at the proximal medial side of this vessel. The lymph node was tested with the lymphoscintigraphy gamma probe and was noted to have activity in the 6,000s. This lymph node was elevated with Singley forceps and dissected away from the artery and lymphatic tissue. The inferior margin of the specimen was ligated, divided, and removed. The gamma probe confirmed this to be the sentinel lymph node with detection numbers in the 6,000s. The inguinal node site was irrigated and excellent hemostasis was noted. Camper's fascia was approximated with 2-0 vicryl. The sub-dermis was re-approximated with 3-0 Vicryl. The skin was closed with running subcuticular stitches using 4-0 Monocryl suture.
We then turned our attention to the vulvar excision.
The vulva was marked with a fusiform shape with care to obtain a 1-2cm margin around the visible scar. There was no gross residual visible disease. The medial margin was modest in order to preserve the patient's clitoris. A scalpel was used to incise the dermis and epidermis and the subcutaneous fat was then dissected away from the fascia. The fusiform shaped specimen was marked and then sent to pathology for review.
Specimen(s) Received
A:Left inguinal sentinel lymph node
B:Left partial radical vulvectomy
C:Left partial radical vulvectomy, medial margin
FINAL PATHOLOGIC DIAGNOSIS
A. Left inguinal sentinel lymph node, biopsy: No tumor in one lymph node (0/1).
B. left vulva: No residual invasive squamous cell carcinoma